Failure to Maintain Accurate Medical Records and Medication Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents. For one resident, the Physician Order Sheet documented an order for Ativan (Lorazepam) to be administered every eight hours as needed for anxiety, with an incorrect duration of 14 months, exceeding the 14-day limit for PRN anti-anxiety medication. The consent form for this medication was incomplete, lacking documentation of the duration. The error in duration was repeated throughout the resident's chart, including the medication administration record (MAR), which was not revised or discontinued as required. As a result, the resident received a dose of Ativan after the order should have been discontinued. The Director of Nursing confirmed the error was due to a transcription mistake that was not identified in a timely manner. For another resident, hospital discharge orders required the continuation of intravenous Ceftriaxone following treatment for a urinary tract infection, sepsis, and a bacterial infection of the knee. The MAR did not document administration of the antibiotic on several days, with blank spaces where nurse initials should have been recorded. The Director of Nursing, who administered the medication, admitted to not documenting the administrations in the resident's record, resulting in several days of undocumented antibiotic administration.